51黑料

About a year ago, Dory Poholsky was looking for a volunteer opportunity.

The 83-year-old from Kirkwood has long been giving with her time, particularly after her husband, Tom (a for the 51黑料 Cardinals), died in 2001 of brain cancer.

Poholsky has a particular soft spot for veterans. So she asked the if she could start a Saturday craft program. A friend carved children鈥檚 toys out of wood, and she brought them to the VA to have veterans paint and decorate them to give to their grandchildren or other kids.

Poholsky spent time talking to the veterans or playing cards with them. 鈥淥ne of them thought I was a former blackjack dealer from Vegas,鈥� she says.

Soon, she met residents of the 51黑料 Veterans Home in north 51黑料 County who had a story to tell. They told her their care was sometimes inadequate, that some of the veterans were being neglected.

Poholsky went to the state-run facility to see things for herself. She talked with veterans and met family members. Over the past year, she has become convinced that something is amiss.

鈥淭hey are suffering physically,鈥� Poholsky says of the veterans. 鈥淪ome of them are dying. We cannot let this go on.鈥�

On Monday, Poholsky and some of the family members of veterans at the home are planning a news conference to go public with their complaints.

The meeting is scheduled for 7 p.m. at North Kirkwood Middle School. Among the attendees will be former state Rep. Rick Stream, R-Kirkwood, who has been working with Poholsky for months to make sure that state government officials, including Lt. Gov. Mike Parson and Gov. Eric Greitens, are aware of what Stream describes as a 鈥渄isturbing鈥� and 鈥渧ery serious鈥� problem.

The veterans home is the , with three wings and about 300 beds. The home provides 24-hour nursing care to aging veterans, many of them in wheelchairs, some of whom spend their final days there.

Rolando Carter, the administrator of the 51黑料 home for a little more than the past year, says he is aware of Poholsky鈥檚 complaints but believes they are misplaced.

鈥淔or the most part, they were very minor in nature,鈥� Carter told me Friday after giving me a tour of the facility. 鈥淲e did identify that we could do a better job communicating with families.鈥�

In May, Carter met with several of the families who had taken their complaints to Poholsky. He says that as a result of that meeting, the veterans home has added a guest service director and instituted what he calls 鈥渄aily grand rounds鈥� where nurses and administrators familiarize themselves with the health care needs of the veterans in their care.

In September, the federal Department of Veterans Affairs conducted an annual survey of the 51黑料 veterans home and found it 鈥渋n compliance with all federal standards.鈥�

鈥淚 want our veterans to get the best care possible because they deserve it,鈥� Carter says. 鈥淚 think that we as a facility have done everything they鈥檝e asked us to do.鈥�

That鈥檚 not how Poholsky sees it.

In April, she provided Greitens with a 48-page report detailing various complaints from veterans鈥� families.

They include incidents of bedsores and dehydration, being provided the wrong medicine or none at all. She tells stories of individual family members who believe that their loved ones are punished if family members complain about their care.

In August, the top executives of the Missouri Veterans Commission 鈥� Gen. Larry Kay, the executive director; Brian Hunt, the deputy director; and Kim Packard, director of the Homes Program 鈥� met with some of the veterans鈥� families to discuss their complaints.

Poholsky thought there would be changes then, especially with the governor himself being a veteran.

鈥淲e鈥檝e tried everything,鈥� she says. 鈥淚 didn鈥檛 want you or the rest of the press to know about this. But nobody has done anything. We have got to fight for these men, because they sure as hell fought for us.鈥�

William Luebbert survived radiation fallout from an atomic blast.

In the early years after World War II, then a soldier in the Army, Luebbert was stationed at a Nevada post with other unknowing soldiers so the military could test how soldiers a nuclear combat situation.

鈥淎mazingly, he never had cancer,鈥� says his son Jim.

After serving his country stateside during the Korean War, Luebbert settled in Florissant, got married, had a family. He moved up the ladder at McDonnell Douglas, starting as a draftsman. He served his parish, St. Norbert Catholic Church and was active in the Knights of Columbus.

He barely lasted a month in the 51黑料 Veterans Home.

Luebbert, who had ALS (Lou Gehrig鈥檚 disease) and dementia, was admitted to the veterans home off Lewis and Clark Boulevard on July 3. He was 85. A couple of weeks later he celebrated his 86th birthday. By Aug. 7 he was dead.

The way his son describes it, Luebbert, who needed help eating and drinking, was left to die in a facility in which some veterans receive inadequate care. He remembers stopping to see his father and finding him in his recliner, with his mouth very dry. There was water on the table next to him. But his father couldn鈥檛 lift it, and nobody helped him.

鈥淭he conditions are beyond minor complaints,鈥� Jim Luebbert says. 鈥淔amily have to beg for basic care.鈥�

Luebbert was one of more than 100 family members, employees of the veterans home, and veterans who filled the cafeteria at North Kirkwood Middle School Monday night to outline the complaints they have brought to state officials over the declining state of care under administrator Rolando Carter.

The advocates and family members want an independent investigation of the home, and they want top staff at the home, and at the Missouri Veterans Commission, replaced.

鈥淲e have discovered a pattern of abuse, mistreatment and neglect that is shocking,鈥� said former state Rep. Rick Stream, R-Kirkwood. For months, he and Dory Poholsky, 83, a volunteer from Kirkwood, have been visiting the home, meeting with families and employees, and documenting their complaints about care. Their efforts are finally grabbing some attention. The complaints were first reported on Sunday, though state officials have known about them for months.

On Tuesday morning, Lt. Gov. Mike Parson into the complaints about poor treatment of veterans at the home. Gov. Eric Greitens, who appoints the members of the Missouri Veterans Commission, has yet to comment. He was made aware of the issue in March when Poholsky presented him a 48-page document consisting of transcripts of her interviews with family members, veterans and employees.

On Tuesday afternoon, Missouri鈥檚 two U.S. senators, Democrat Claire McCaskill and Republican Roy Blunt, joined Parson鈥檚 call for an independent investigation. In a joint letter to Greitens, the senators asked that such an investigation extend to all Missouri Veterans Homes 鈥渢o ensure that our veterans are receiving the highest quality of care and respect from well-trained, compassionate leaders and staff.鈥�

The home received perfect marks in a U.S. Department of Veterans Affairs survey in September. But that report is flawed, multiple employees said. Carter was given advance notice of the inspection, they said, and he was able to clean up problems and add staff before the visit.

鈥淚 knew about the survey a week before it happened,鈥� Luebbert said. 鈥淎ll the families and employees did.鈥�

One of those employees, Troy Rooks, 61, a social worker who is himself a Marine Corps veteran, said that Carter retaliates against employees and family members who complain about the treatment veterans receive.

鈥淩ight now, veterans are suffering,鈥� Rooks said. 鈥淭his must stop.鈥�

Among the allegations made by the veterans and their families is that medications are often late, or incorrect. Veterans are falling, are dehydrated and are left in soiled clothing. They have bed sores that require hospitalization; records are falsified; veterans are dying.

Carter has said he has increased communication with families as a result of what he calls 鈥渕inor鈥� complaints. And the deputy director of the , Bryan Hunt, read a statement in a closed meeting of the commission Monday in which he blamed some of the complaints on race. Carter is the first African-American director of a Missouri Veterans Home.

鈥淚t is my opinion that at least some of the individuals involved had a racist agenda that they wanted to accomplish,鈥� Hunt鈥檚 statement reads.

That statement caused even more anguish with family members of the veterans at Monday night鈥檚 meeting in Kirkwood. Had Hunt been there, he would have seen that many of the families and employees who are complaining are black.

Among them is Cheri DeJournette, who says her father, Robert, a retired Air Force officer, went 14 days without bathing this summer. She described being physically removed from the home by three police officers after Carter refused to allow her to attend a residents鈥� council meeting. Like many of the family members, she has full power of attorney over her father, and was invited to, and had previously attended, such meetings.

And then there was Curtis Washington, 80, an Army veteran. 鈥淲e need more care,鈥� Washington said Monday, shaking and crying, from his wheelchair.

His wife, Sandra, said she鈥檚 worried for him. Because he and his family have spoken out, she鈥檚 afraid he will become a target.

鈥淚t has gotten worse,鈥� she says of the home鈥檚 care during the three-and-a-half years her husband has lived there. 鈥淚 am afraid Curtis will soon leave us in death if things do not change.鈥�

In June, Margaret Coulter found out a work colleague was wanted for murder.

Coulter was the registered nurse supervisor at the 51黑料 Veterans Home in north 51黑料 County, a state-run nursing facility that houses up to 300 veterans.

According to court documents, on June 23, Coulter 鈥渂ecame aware鈥� that a worker in the dietary department, Jerome Leon Buress Jr., was wanted by police for questioning in connection with a triple murder.

It was the most heinous of crimes.

On June 2, somebody 鈥� police have since with the crimes 鈥� walked up to a Honda Civic near Beacon and Lillian avenues in the city of 51黑料 and started firing a weapon into the car. Killed were Derrick Irving, 27, Jessica Garth, 24, and Julian Hayes, 37. Also severely injured was 7-year-old Deniya Irving, who became the latest child shooting victim in 51黑料 to energize community outrage.

The little girl who was shot in the head and left for dead . Her parents are dead.

Coulter told a Ferguson police officer who was working security at the home about Buress. The officer informed other police departments in the area. The next day, with Buress not yet arrested, Coulter told the administrator of the home, Rolando Carter, about the situation. She was worried for the veterans and their families, she said. Carter, she said, had not notified staff of their potentially violent co-worker.

Coulter 鈥渃omplained to Carter regarding his lack of concern and action for the safety of residents and visitors,鈥� say court records. In response, 鈥淐arter told (Coulter) that he had taken care of it by taking Buress off the schedule. Carter also stated that what Buress did 鈥榟appened somewhere else, not here.鈥欌��

One day later, Buress turned himself into police.

Five days after that, Coulter was fired.

In September, she sued the Missouri Veterans Commission alleging retaliatory termination. She is represented by 51黑料 attorney Jerome Dobson. According to her lawsuit, filed in 51黑料 County Circuit Court, Carter told her 鈥渢hat she was terminated because she spoke to the police regarding Buress.鈥� Carter declined to comment on the lawsuit.

Coulter is not the first employee of Carter鈥檚 to suggest the man in charge of care for 300 51黑料 veterans has a vindictive streak. At a public meeting Monday night at North Kirkwood Middle School, several employees and family members of veterans said that Carter , employees and family members who have complained about what they think is the declining level of care there.

There appears to be a simple rule at the 51黑料 Veterans Home.

If you fight for better care for the veterans who live there, you鈥檙e out.

Take Dr. Naveed Razzaque.

As medical director of the facility for much of 2016, Razzaque noticed what he thought was a dangerous trend. 鈥溾�� it is my belief the nursing staff felt they did not have enough staff or training to deal with the veterans when they became agitated and therefore preferred to use anti-psychotic medications to control the veterans.鈥�

Razzaque wrote that sentiment in a letter emailed to the offices of Gov. Eric Greitens and Lt. Gov. Mike Parson on Feb. 7 this year, after he had been removed by Carter as medical director. The letter contains numerous allegations concerning inadequate care for veterans at the facility and requests a state investigation into the 51黑料 facility, the veterans home program, and the Missouri Veterans Commission that runs it.

After sending the letter, Razzaque had a meeting with Parson and some of his staff to press his case. He said he never heard anything from the governor鈥檚 office. Parker Briden, the governor鈥檚 spokesman, said nobody in the governor鈥檚 office has a record of receiving Razzaque鈥檚 letter. This week, after my columns on the complaints of the veterans, their families and their advocates, and calls for an independent investigation made by Parson and Sens. Claire McCaskill and Roy Blunt, Greitens said he planned to order an investigation by the Department of Public Safety.

A good place to start would be the letter the governor鈥檚 office says it never received.

In it, Razzaque describes much more than what he believes to be an over prescription of anti-psychotic drugs.

鈥淚t is my opinion there was disregard by (the veterans home administrator and Missouri Veterans Commission central office staff) as to medical directions provided for the health care and safety of veterans with dementia,鈥� Razzaque wrote. In his letter, he pointed out that according to federal statistics, Missouri has among the highest rates of use of anti-psychotic drugs in nursing homes. He said he asked the veterans commission, led by Gen. Larry Kay, to convene all seven medical directors of the state鈥檚 veterans鈥� homes to discuss the issue. Razzaque said he was ignored.

鈥淥n many occasions comments were passed through nursing staff from the MVC leadership that the Medical Director 鈥榠s hired by us and works for us; we tell him what to do,鈥欌�� Razzaque wrote Greitens.

Razzaque, who is chief of medicine at SSM Health DePaul Hospital and a board member of the State of Missouri Nursing Home Administrators, brought many issues to the governor鈥檚 and lieutenant governor鈥檚 attention. He outlined problems with staffing and employee retention, medical records and lab testing, training and communication.

鈥淚 strongly feel that our veterans are the heroes of our nation and deserve better,鈥� Razzaque wrote.

Nine months later, the governor has apparently reached a similar conclusion.

Gov. Eric Greitens is right.

U.S. Sens. Claire McCaskill and Roy Blunt should read the Veterans Affairs audit of the regional VA office in 51黑料. But not for the reasons the governor suggests.

The request came in a letter that Greitens, a Republican, sent Thursday to McCaskill, a Democrat, and Blunt, a Republican. The letter 鈥� full of snark and political platitudes 鈥� was a response to one sent by the two senators asking the governor to open an investigation into complaints of poor medical care and bad treatment of employees at the 51黑料 Veterans Home, a state-run facility. The complaints came to light on Oct. 29, and then a public meeting the next day, followed by numerous other media reports.

Greitens didn鈥檛 take kindly to the senators asking him to do that which veterans, family members, employees of the facility, and Lt. Gov. Mike Parson 鈥� also a Republican 鈥� were requesting.

鈥淔rankly, it鈥檚 good to see some signs of life out of Congress,鈥� the governor wrote. 鈥淎 lot of us back home have been wondering what you鈥檝e been up to.鈥�

In fact, at the time the letter was sent, McCaskill was 鈥渂ack home鈥� visiting her sick husband in the hospital.

But I digress. Back to the governor鈥檚 letter.

鈥溾�� you probably knew about these investigations before you sent a letter 鈥榬equesting an investigation.鈥� Or maybe you didn鈥檛?鈥� Greitens wrote. 鈥淏ecause in the other part of your letter you asked for a copy of the VA report on the 51黑料 Veterans Home. The VA publicly released that report back in September. If you lost your copy, you can Google 鈥�51黑料 Veterans Report Survey VA.鈥� It鈥檚 the second link down.鈥�

As my friends at 51黑料 Public Radio , there was a VA report two links down after that search (after coverage of Greitens鈥� letter, the result has dropped lower), but it was not the survey the governor was talking about.

The annual survey of the 51黑料 Veterans Home was linked online to my Sunday column outlining the complaints of veterans and their families. It is a 57-page document that lists 158 categories of various standards that are analyzed to see if they are met. Every category is met according to the survey. What鈥檚 stark about it is its perfection.

No questions. No comments. No details. No mentions of interviews with family, employees or the medical director who says he spoke with the survey team.

The entire report is blank except for the word 鈥渕et鈥� being printed 158 times.

Perhaps the governor doesn鈥檛 find that curious. Knowing as he did in July 鈥� if not several months earlier 鈥� that there were serious complaints about the facility being made by veterans, their families, their employees and advocates, how could the report look so pristine?

The answer, according to employees and family members of the veterans who live there is that home administrator Rolando Carter had a heads-up and took extraordinary measures to prepare for the VA visit. Social worker Troy Rooks said he knew of the visit at least a week in advance. So did certified nursing assistant Rucell Douglass. So did family member Jim Luebbert, whose father had died a month before, and medical director Dr. Naveed Razzaque. Even veterans advocate Rick Stream, a former state representative, knew of the impending visit. They all find the report鈥檚 conclusions to be dubious.

In his letter to Sens. McCaskill and Blunt, Gov. Greitens calls the annual survey an 鈥渋nvestigation.鈥�

But it doesn鈥檛 read like one.

That鈥檚 why his Google error is so telling.

The report he accidentally directed McCaskill and Blunt to is actually an in the federal VA hospital at Jefferson Barracks. The audit, conducted by the Office of Inspector General, is 30 pages of rich detail. In reviewing more than 1,000 claims, the auditors found several errors in processing, from over- and underpayments to veterans and providers, improper paperwork, delays and other errors. The auditors called for more training and better attention to detail. There was an opportunity for VA administrators to respond to the findings and make recommendations.

For anybody who has spent much time reading such audits and investigations, the VA report comes off as a serious, thorough effort.

It is the sort of investigation that is needed regarding serious complaints that have been raised about veterans鈥� care to Greitens or Parson or both since at least February.

Such a rigorous examination has yet to take place at the 51黑料 Veterans Home or the Missouri Veterans Commission.

I know. Because I Googled it.

Randy Reeves is a wanderer.

He鈥檚 been that way for much of his adult life, says his sister, Cathy Gardner.

鈥淗e used to go dark on us,鈥� Gardner says, describing those times when Reeves would just take off, living with friends or on the streets, traveling around the country. She lives in Jonesboro, Ark., where she keeps track of her brother from afar. These days Reeves, 65, lives at the Missouri Veterans Home in 51黑料.

Reeves was born in 51黑料. His family moved to Arkansas when he was 7. He joined the Army at 17, was later diagnosed with mental illness, and has been battling it most of his life.

In October, Reeves signed out from the veterans home, saying he was going to see a friend.

His social worker, Troy Rooks, was out of the office when Reeves left the facility. Rooks says he called to check on him over the weekend and found out he hadn鈥檛 returned. So he called the phone number of Reeves鈥� friend he had gone to visit and asked if the disabled veteran needed a ride back to the veterans home.

鈥淗e told me he had been discharged,鈥� Rooks says.

When the social worker got into work on Monday, he was flabbergasted. He had an email saying Reeves had been discharged from the home. He no longer lived there.

鈥淭here was no discharge care plan. No mention of where he would go,鈥� Rooks says. 鈥淲e didn鈥檛 know if he had food, clothing or water. We cannot discharge a disabled, mentally ill veteran like that.鈥�

Rooks says he met with the administrator of the home, Rolando Carter, who told him Reeves had requested and been granted a discharge from the home. Rooks knew Reeves was in no condition to make such a decision. The Missouri Veterans Home regulations call for a 30-day notice before such a discharge, consultation with medical staff and the social worker, details on where they will be transferred and multiple levels of review.

During at North Kirkwood Middle School last month, at which veterans, their families, and employees testified about what they said was poor care at the home under Carter鈥檚 watch, Rooks recalled when Reeves came to the home.

The veteran had been receiving care from the nonprofit , which provides services to the mentally ill, veterans and the homeless. 鈥淭hey adored this man,鈥� Rooks recalls, and he promised the social workers there he would look after Reeves.

He was shocked that Carter would discharge him from the facility without so much as a discussion with his medical team or a clue about where he would end up.

Rooks says he begged Carter to change his mind, but that he wouldn鈥檛. So the social worker went back to his office and documented the meeting and entered it into the medical records of the veterans home.

In Arkansas, Gardner received a call that her brother had been discharged.

鈥淚 didn鈥檛 know what was going on,鈥� she says. 鈥淏less his heart, I know he isn鈥檛 easy to deal with at times. He is physically unable to take care of himself.鈥�

The next day, Rooks was called into Carter鈥檚 office and told to change the documentation he entered into the computer system. He refused. Eventually, Carter gave him the keys to the facility鈥檚 van and told him to go pick up Reeves.

鈥淗e looked like he was glad to see me,鈥� Rooks says.

Reeves is back at the Missouri Veterans Home. 鈥淗e needs to be there,鈥� his sister says. She credits Rooks with 鈥済oing to bat鈥� for her brother.

Now Rooks, 61, a Marine Corps veteran, is facing rocky times. After refusing to change the document he filed regarding his meeting with Carter, Rooks received a letter of reprimand from the administrator and was put on paid leave for a few days.

Carter did not return requests for comment. He has previously declined to answer questions about individual residents or employees at the Missouri Veterans Home, but has defended the care under his watch.

On Monday, Rooks filed a discrimination and whistleblower complaint with the Missouri Commission on Human Rights. 鈥淚 believe that my employer is not following the proper policies, procedures, and regulations associated with veterans鈥� care,鈥� he wrote. 鈥淚 believe that Mr. Carter retaliated against me because I reported that Mr. Carter was violating a veteran鈥檚 rights.鈥�

Rooks鈥� complaint mirrors those made by multiple veterans, family members and employees going back to at least February, when the former medical director wrote Gov. Eric Greitens and Lt. Gov. Mike Parson into the care at the home. Last week, Greitens said he would order an independent investigation of the facility.

In a letter to the Missouri Veterans Commission dated Nov. 3, Parson wrote that 鈥渋t is clear to me the 51黑料 Veterans Home has serious problems, and has had a systemic pattern of them for several years.鈥�

Rooks agrees with that analysis. He just hopes that whomever eventually investigates, they get started soon, while Reeves still has a place to live, and Rooks is still employed.

鈥淚 need this job,鈥� Rooks says, 鈥渂ut I鈥檓 not going to back down.鈥�

Tony Hastings believes Rolando Carter needs a lesson in what it means to be a veteran in America.

A 51黑料 native, Hastings is 79. He joined the Army in 1958 and was assigned to the intelligence corps in Honolulu. Three years in, an ALS diagnosis cut his service short. A paraplegic, he鈥檚 been in a wheelchair for 30 years. In 1989 he was told he only had a few years to live.

鈥淕od gave me 25 extra years, and I鈥檓 still going,鈥� Hastings said.

We met Tuesday at Ameristar Casino in St. Charles. He was there with other residents of the 51黑料 Veterans Home 鈥� Carter is the administrator there 鈥� for a regular monthly outing.

Hastings and another veteran, fellow 51黑料 native Britt Vaughn Sr. 鈥� he鈥檚 80 鈥� wanted to tell me about what they believe is inadequate care, sometimes bordering on abuse, at the state-run home where they live. They knew Carter wouldn鈥檛 let me talk to them there, so they asked the daughter of another veteran to arrange our visit.

While we were having lunch and chatting, Carter got wind of our visit. He called an employee who was helping the veterans at the casino 鈥� nearly all of them use wheelchairs 鈥� and the employee interrupted our visit. He seemed chagrined but told the men who long ago served their country to defend the First Amendment and other freedoms that they didn鈥檛 have to talk to me.

鈥淚 can talk to anybody I want to,鈥� Vaughn snapped back. He had a few other words for the administrator, too, possibly learned during his stint in the Army in the 1950s.

鈥淲here do our freedoms end and begin?鈥� Hastings asked. It takes him a lot of energy to put his words together, but his mind is still clearly sharp. 鈥淚 don鈥檛 think it is any of his business.鈥�

What is Carter鈥檚 business is what the veterans have to say about care in the home that he directs.

鈥淚t鈥檚 not good,鈥� says Hastings, who grew up on 13th Street in north 51黑料.

, various veterans, family members, employees and volunteers have been trying to get the Missouri Veterans Commission and Gov. Eric Greitens to pay attention to their complaints. After U.S. Sens. Claire McCaskill and Roy Blunt and Lt. Gov. Mike Parson called for an outside investigation, Greitens said he would order one. It鈥檚 being conducted by Harmony Healthcare International.

Hastings and Vaughn believe the issues at the home stem from similar problems: There aren鈥檛 enough employees, and some of them are poorly trained.

鈥淲henever you want something you practically have to beg for it,鈥� Hastings says. 鈥淚t always takes so much time to get anything.鈥�

Hastings says he often goes days without a shower or bath. The whirlpool at the home is often broken. Recently, he was left naked in his bed for several hours.

鈥淚 kept calling on my button to try to get somebody,鈥� he says. 鈥淚鈥檓 sorry, but I just can鈥檛 do it myself.鈥�

Vaughn knows he has a target on his back. He doesn鈥檛 care. Taped to his wheelchair is a sign: 鈥淣either am I going to back down,鈥� it says. The sign is a tribute to social worker Troy Rooks, with Carter when he wouldn鈥檛 let the administrator improperly discharge another veteran who had no place else to go. Rooks saved the veteran鈥檚 room at the home but was disciplined when he wouldn鈥檛 alter a report about the incident he entered into the veteran鈥檚 medical record. After Rooks told me he would continue to stand up for veterans even if it cost him his job, Carter suspended him.

The biggest problem at the home is not having enough employees, Vaughn says. As a result, employees 鈥� nurses, nurse鈥檚 assistants, social workers 鈥� are forced to work extra shifts even after they have put their 40 hours in, sometimes making it difficult for them to manage affairs in their lives.

鈥淭hey call it mandation,鈥� Vaughn says. 鈥淚 call it slavery. These people cannot work 16 hours in a row and be efficient. It鈥檚 disrupting the whole place.鈥�

Vaughn knows a thing or two about disruption.

He joined the Army the first time when he was 16, just a sophomore at Vashon High School.

It took three months for the Army to figure out he was too young, he said, but they told him he could come back after he graduated. He did, serving in Germany. Back home in 51黑料, he worked as a riveter at McDonnell Douglas before becoming a drill press operator and shop steward at Carter Carburetor. He got a degree at 51黑料 University. He and his wife, Irene, raised three sons. Vaughn has been at the veterans home since 2014.

Before our visit is over, another employee comes over to our table. Carter has asked her to monitor the rest of our interview, she says.

Fine, Vaughn says. But he鈥檚 not about to hold back.

鈥淚鈥檓 no angel,鈥� he says. 鈥淏ut I ain鈥檛 no dog either.鈥�

He wipes away a tear while he thinks about the place where he expects to die.

鈥淚t鈥檚 a damn shame. If they don鈥檛 stop that mandation, we won鈥檛 have a place to live. I鈥檝e got no place to go.鈥�

Missouri鈥檚 state-run veterans homes have a distinction that separates them from other skilled nursing home providers 鈥� and not in a good way.

鈥淭hey are the only skilled nursing facilities in the state of Missouri with a statutory ability to investigate themselves.鈥�

That sentence appears in an investigative report delivered to the Missouri Veterans Commission on Oct. 19 by the office of Lt. Gov. Mike Parson.

The report was emailed by an anonymous leaker to numerous reporters last week. Bill Bellomy, Parson鈥檚 director of veterans affairs, confirmed to the Post-Dispatch that he wrote the report and conducted the investigation.

In it, he outlines numerous problems with the 51黑料 Veterans Home that have come to light in the past month, with veterans, their families and employees under the direction of administrator Rolando Carter and his bosses at the veterans commission, including director Gen. Larry Kay.

The complaints, verified by Bellomy in an investigation that began in February, include improper medication, including overuse of antipsychotics, the inability 鈥渢o hire and retain quality personnel,鈥� a lack of transparency and honesty in investigation of complaints, and a 鈥渃omplete loss of faith鈥� between veterans, families and the administration of the Missouri Veterans Commission.

The release of the report comes as Gov. Eric Greitens announced last week that an outside firm 鈥� Harmony Healthcare International 鈥� retained by the Department of Public Safety would be conducting what the Republican governor is calling into complaints at the home. But the other three inquiries that Greitens is referencing 鈥� one by the veterans commission, one by the DPS and one an annual survey by the federal Department of Veterans Affairs 鈥� raise more questions then they answer.

鈥淣o one outside the commission has seen the internal report,鈥� Bellomy says, 鈥渁nd I have not been able to ascertain if DPS produced a written report.鈥�

The one written report 鈥� an annual survey conducted by the federal Department of Veterans Affairs 鈥� found a clean bill of health. The 57-page report is mostly blank as it lists 158 standards that have been met. It is in stark contrast to the state鈥檚 investigations on other nursing homes in the state.

In Missouri, the Department of Health and Human Services maintains a database of nursing home, hospice and home health care inspections. Nearly all find some problems 鈥� caring for bedridden senior citizens is difficult work. But providers offer courses of correction, and inspectors either approve the changes or kick the complaint to a higher level.

Not so the VA鈥檚 report in September on the 51黑料 Veterans Home.

The families and veterans who have spoken to me in recent weeks 鈥� many also spoke to Bellomy 鈥� say the Veterans Affairs survey wasn鈥檛 conducted until Carter got a two-week notice. And the surveyors didn鈥檛 pay attention to many of the veterans and family members, they say.

鈥淭hey didn鈥檛 interview us,鈥� says Cheri DeJournette, whose father, Robert, lives at the facility. When she tried to meet with the surveyors to tell them about her father being burned in a shower that was too hot, they told her to 鈥渞emove her father from the home and hire in-home care,鈥� according to Bellomy鈥檚 report.

Most telling is this: In each of the previous three years, Veterans Affairs surveyors found deficiencies and the veterans home proposed corrective actions, and the public documents contain significantly more information.

The Post-Dispatch obtained the surveys of the 51黑料 Veterans Home from 2014 and 2015 in an open records request. The 2016 report wasn鈥檛 provided, but a letter from the VA indicates there were deficiencies found that were later appealed by the 51黑料 Veterans Home.

While Bellomy found multiple problems verified by various sources, the other investigations came up empty. That caused him to suspect the other investigators weren鈥檛 necessarily looking out for the best interests of veterans.

鈥淭here needs to be a change in the leadership of both the Missouri Veterans Home, 51黑料 and the Missouri Veterans Commission,鈥� Bellomy wrote in his recommendations.

鈥淭he complaints and issues captured in this report have been brought to the attention (of commission leaders) numerous times by Veterans, Family members, and staff with nothing being done to correct them. If anything, there seems to be a closing of ranks, threatening of employees, and making of veiled threats to have veterans removed from the Veterans Home or further medicated. Anything less than a new group of leaders will only display more of the same, as opposed to sustained change and improvement. This will lead to the impression that Missouri, like the Department of Veterans Affairs, is more interested in hiding issues than fixing them.鈥�

The night before Thanksgiving, Tom Constantin threatened to kill himself.

It wasn鈥檛 the first time; probably won鈥檛 be the last.

鈥淚 struggle during the holidays,鈥� says Constantin, 59, an Army veteran who suffers from post-traumatic stress disorder. By the time he got off the 911 call last Wednesday, he had already started calming himself. Buddhist meditation techniques help, he says, but he went to Barnes-Jewish Hospital anyway and was there about 12 hours before they let him go.

There are a few things that have Constantin down lately. On Wednesday, his landlord at Park Place Apartments in 51黑料 sued for $277 in back rent. In October, Constantin says he gave 30 days鈥� notice that he was going to move.

He thought he was going home.

Constantin grew up in Dellwood. He graduated from Riverview Gardens High School. For the past few months, he鈥檚 been trying to get a room at the 51黑料 Veterans Home, not far from there. The way Constantin tells it, administrators at both the home and the Missouri Veterans Commission told him he had a place there.

鈥淭hey promised me a bed three times,鈥� he says. In August. In September. In October.

There was one problem.

For the past six years, to help him deal with his PTSD, Constantin has had an emotional support dog.

She was a pug named Lilly.

鈥淪he was everything to me,鈥� he says.

In August, he gave Lilly to the . The admissions folks at the 51黑料 Veterans Home told him they didn鈥檛 allow support dogs. Constantin knew he needed the daily services provided at the home more than he needed Lilly. So when they told him he could move in, he gave up his lifeline.

A big man who worked in the Army as a combat engineer, Constantin breaks into tears at the mere mention of Lilly. 鈥淎ll I had was that dog. Once they made me give her away, my life ended.鈥�

He still wants to move into the veterans home. But he doesn鈥檛 know what the holdup is.

Every month, Constantin says, he gets a different answer as to why he doesn鈥檛 have a room at the 300-bed facility. He was at the top of the list, until he wasn鈥檛. He was told 鈥� twice, he says 鈥� not to call higher-ups or it would diminish his chance to get a room. He called anyway.

They told him they could place him at a private facility with his veterans benefits, but when he called, the facility said he couldn鈥檛 live there because he had been suicidal.

He felt like he was in a vicious playback loop facing so many of our nation鈥檚 veterans. In 2014, 18 percent of the adult suicides in the U.S. were veterans. That year, , on average. Six of those 20 were users of veterans services.

Constantin knows the statistics and he doesn鈥檛 want to become one. It鈥檚 why he sought placement in the state-run home. Despite reading about the into care issues at the home, Constantin figured it鈥檚 where he belonged. He doesn鈥檛 have family anymore. He doesn鈥檛 like living in the city. He stays to himself mostly. Lately, since Lilly鈥檚 been gone, he wakes up with 鈥渢he terrors.鈥�

鈥淚鈥檓 freaking out,鈥� he says.

He鈥檚 supposed to be out of his apartment by the end of the month, and he faces legal action if he doesn鈥檛 comply. So he keeps calling the 51黑料 Veterans Home to check on his room. He calls supervisors. And when they tell him not to call their supervisors, he calls them, too. This month he filed a complaint with Melissa Wilding, the ombudsman for the Missouri Veterans Commission. He called the governor鈥檚 office, too.

Lilly found a good home with a woman who loved pugs, Constantin says.

He misses his dog. He knows he needs help.

He waits.

Sen. Rob Schaaf walked slowly into his corner office on the fourth floor of the Missouri Capitol.

The unmistakable smell of microwave popcorn wafted through the air.

Schaaf paused, turned to his aides, and asked:

鈥淚s that popcorn?鈥�

It鈥檚 not hard to understand why the St. Joseph Republican鈥檚 senses were slow to engage.

He was about 20 hours into a more than of a bill pushed hard by Ameren Missouri and other investor-owned monopoly utility companies to make it easier for them to raise your electric rates. From Wednesday afternoon to Thursday afternoon, barely a month into the session, Schaaf and a small band of cohorts including Sen. Doug Libla, R-Poplar Bluff, and Sen. Gary Romine, R-Farmington, held the floor while Senate leadership floated the threat of cutting off debate on the bill sponsored by Sen. Ed Emery, R-Lamar. At times, Democrats Jill Schupp of Creve Coeur and Maria Chappelle-Nadal of University City also jumped in to help.

That the bill has the votes to eventually pass is a foregone conclusion.

But that Ameren and its monopoly partners, and their phalanx of nearly 100 lobbyists, would force the Republican-led Senate to threaten to cut off a Republican-led filibuster so early in the session had Capitol veterans shaking their heads.

The Ameren folks say this debate is about jobs. Missouri鈥檚 regulations governing utilities make it harder to 鈥渕odernize the grid,鈥� they argue. Their supporters, including Gov. Eric Greitens, suggest higher rates will lead to economic development nirvana.

That was the same argument they made several months ago when the Republican governor to try to pass a bill that had many of the same handouts to monopoly utility companies that are in this session鈥檚 bill. In the special session, most of the goodies were carved out. Instead, lawmakers passed a bill intended to lure a phantom steel mill to southeast Missouri.

Those jobs never materialized, so now the companies that determine how much most Missourians pay to keep their lights on are back, pushing hard to pass a bill that everybody agrees will make it easier for Ameren to raise rates without the pesky getting in the way.

鈥淭he legislation itself is really about giving them higher profits for no additional investment,鈥� says John Coffman, an attorney and lobbyist for , which opposes the bill. 鈥淥ur rates are low. Monopoly utility profits are high. Our reliability is already great. This is just political opportunism.鈥�

That was the point Schaaf tried to drive home at various times during his filibuster.

On Thursday afternoon he started reading campaign contributions made to Greitens and lawmakers from utility companies and their executives. More than $900,000 was given to legislators in the past election cycle, Schaaf said. He scrolled through his phone and read off maximum $2,600 contributions from various executives of Ameren and other monopoly utility companies to Greitens.

Those, of course, are likely a pittance compared to the money given to the governor through his A New Missouri nonprofit that doesn鈥檛 report its donors.

鈥淭here is no connection whatsoever鈥� between the donations and the Senate rushing to get the Ameren bill through so early in the session, Schaaf said. He was being sarcastic, of course. 鈥淭hat would be improper,鈥� he said. 鈥淚 would never support such a tawdry鈥� allegation.

Schaaf鈥檚 words, as well as the unusual threat from Senate leadership of using the rare previous question motion to stop his filibuster, tell consumers all they need to know about .

It鈥檚 all about the money.

So while Ameren and its supporters pitch the alleged 鈥渃ap鈥� on yearly rate increases in the bill being set at 2.85 percent for the next few years, Coffman points to the exceptions and surcharges elsewhere in the bill that could lead electric rates to rise about 20 percent over the next seven years.

There鈥檚 a reason, Schaaf said, that Ameren and its Senate enablers try to pass such legislation in the dark of night when few people are paying attention.

The bill is basically a tax increase passed during an election year. Senior citizens living on fixed incomes will pay a few pennies more to microwave a bag of popcorn, and that money will go to shareholders of the monopoly utility in the form of increased profits that no longer need to be approved by the regulators meant to balance out the needs of monopolies and consumers.

Early Thursday evening, Schaaf sat down. The filibuster ended. The bill advanced. And the stench of money in politics filled the air.